1. Shared Decision-Making
Consumer-Driven Care vs. Patient-Centered Care
Maggie Mahar, Ph.D. Fellow, The Century Foundation
Author, Money-Driven Medicine: The Real Reason Health Care Costs So Much (Harper-Collins 2006)
Blog:

2. Is the Patient Really a Consumer?
How do most consumers put a lid on prices?
By waiting until rivals come into the marketplace and prices come down
But the cancer patient can’t wait, and in the world of cutting-edge medical technologies prices rarely fall.
“the market…effectively provides no mechanism for price control in oncology—other than companies’ goodwill and tolerance for adverse publicity.” (Morgan Stanley Analyst Steven Harr, M.D. WSJ 3/15/07)

3. Unlike Other “Shoppers” the Patient:
Can’t rely on a friend’s experience
Can’t rely on his own past experience (3/4 of health care dollars are spent on products and services that a patient has rarely, if ever, purchased before)
Knows there are no warrants, no guarantees, no returns…
THIS IS WHY THE PURCHASE OF HEALTHCARE MUST BE A TRANSACTION BASED ON TRUST
How can the patient possibly go forward with the transaction if he didn’t trust the seller?
This is a market where caveat emptor cannot apply

4. Compare the Two Relationships
Consumer vs. Seller
Adversarial relationship (caveat emptor)
Consumer can’t trust seller to put consumer’s interests first, must demand the best care at the best price
Doctor and Patient
Collaborative relationship (based on trust)
Patient must trust in doctor’s knowledge and professionalism
“the patient-physician relationship is very different from the one we accept in the commercial marketplaces because it requires patients and health professionals to work cooperatively rather than as adversarial buyers and sellers. Mutual trust contributes to the efficiency of production.
(Victor Fuchs)

5. Shared Decision-Making
Discussing Options, Risks, and Benefits
Physician shares his knowledge and experience
Patient shares his priorities, values, fears and preferences
Medicine that is “patient-centered” not “consumer-driven”

6. Together, Patients & Physicians Confront:
UNCERTAINTIES of Medicine
“The core predicament of medicine, its uncertainty, is the thing that makes being a patient so wrenching, being a doctor so difficult, and being part of the society that pays the bills so vexing… “With all that we know today about people and diseases and how to diagnose and treat them, it can be hard to grasp…how deeply the uncertainty runs.” (Dr. Atul Gawande, Complications: A Surgeon’s Notes on an Imperfect Profession)

7. Uncertainty: Grappling with the Odds
Detecting and Treating Early Stage Prostate Cancer
Early Detection: A PSA Test and Biopsy
20 out of 100 men eventually will be diagnosed
3 out of 100 will die of prostate cancer
Which 3???
Disease progresses so slowly, many men will die of something else long before experiencing symptoms

8. Treating Prostate Cancer
Most Common Complications
Impotence?
Incontinence?
Treatment Options
Surgery
External Beam Radiation
Radiation Seeds (brachytherapy and other new types of radiation)
“Watchful Waiting”
Source: Foundation for Shared Medical Decision-Making 2007

9. Which Option Is Better? There Is No Right Answer
A Tough Decision for Physicians and Patient Made Even Tougher:
NO SOLID EVIDENCE THAT EARLY DETECTION & TREATMENT OF PROSTATE CANCER SAVES LIVES
National Cancer Institute: “…it is not clear whether this earlier detecting and consequent earlier treatment leads to any change in the natural history and outcome of the disease.”
American Cancer Society: “…the current evidence about the value of testing for early prostate cancer detection is insufficient to recommend that average-risk men undergo regular screening… ACS recommendations emphasize shared decision-making.”
PSA testing should be “offered” to men beginning at age 50, but not “recommended”
Instead doctors should discuss the “potential benefits, limitations and harms associated with testing” and then let the patient decide.

10. Taking the Patient’s Preferences Into Account
Is he a risk-taker?
“I don’t worry too much about uncertainty—all of life is uncertain. You never know what’s around the next corner. In the meantime I want to enjoy what I have.” (Chose Watchful Waiting)
“If something is going to happen, I want it to happen. Fix it and get it over with.” (Chose Surgery)
Some patients want more autonomy, some want LESS.

11. Can Shared-Decision Making Contain Costs?
When patients share in decision-making about elective treatments:
20% OR MORE DECIDE NOT TO GO AHEAD WITH THE PROCEDURE
SAVING MONEY IS NOT THE GOAL.
Goal: Better Quality
To give every patient AS MUCH care as he needs—and no less
To give every patient AS MUCH care as he wants—and no more
BUT SAVING MONEY IS A WELCOME BY-PRODUCT.

12. Don’t Shift the Burden to “the Consumer”
Instead, it is up to health care providers to raise the quality of care while sharing what they know with patients about risks and benefits.
“…we need to think less exclusively in terms of consumer choice and more in terms of consumer welfare…it may be time for bioethics to [move] away from patient choice and toward changing the medical care system so that it delivers a better product. “To put the point provocatively, it might be time to think about giving patients what we think they want, but have not been able to secure for themselves. (Carl Schneider, Professor of Law and of Internal Medicine, University of Michigan, The Practice of Autonomy)